If There Is No Acute Process, Just Say So

Impression: 1) Mild to moderate spinal stenosis with moderate bilateral neuroforaminal narrowing at the C4 level.2) Mild spinal stenosis with mild right and moderate left neuroforaminal stenosis at the C5 level. 3) Mild bilateral neuroformainal narrowing at the C6 level. No compression fracture or spondylolithesis.

In modern health care, we deal with incredibly complex patients who present with a myriad of medical problems. Clinical teams taking care of these patients may not know the full history, and often lack the time to fully delve into the details of how every problem in the patient’s medical history came to be. In this context, imaging plays a crucial role in distinguishing between acute and chronic problems within the numerous clinical findings present in the patient. Sometimes, radiologists and clinicians alike can get caught up in the myriad of findings and focus on details that are not clinically significant.[[{"type":"media","view_mode":"media_crop","fid":"63829","attributes":{"alt":"Mina S. Makary, MD","class":"media-image media-image-right","id":"media_crop_7458241618848","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"8141","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 244px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Mina S. Makary, MD, Department of Radiology, The Ohio State University Medical Center","typeof":"foaf:Image"}}]]

We should try to mitigate this error by dictating the impression of the radiology report in the order of clinical relevance and acuity. The impression, first and foremost, should answer the question of the referring physician. Other findings should be listed in order of acuity to direct the clinical team’s attention to what should be addressed first. Some radiologists dwell on chronic findings that may not be acutely clinically relevant without explicitly stating that they are not part of the acute picture. While it is expected and necessary to describe chronic findings, delving into the complexities of a chronic finding, especially if it was described thoroughly in a prior study, can confuse the treating physician. When it is clear from imaging that are no acute findings contributing to the clinical picture at hand, it is best to clearly and succinctly state “No acute process” as the first line of the impression. Otherwise, even in cases with few medical problems, a detailed description of an unrelated finding without excluding an acute process can distract the clinical team.

This was the case in the previous cervical spine CT anecdote where the impression described chronic degenerative changes of the spine. The ordering physician had requested the study because the patient was an elderly woman with a new neck pain after a fall, and asked to “rule out fracture.” The radiologist ruled out a fracture, but described the chronic changes in detail first without explicitly stating that these were chronic-appearing findings and were present on prior studies. The primary physician assumed that these were at least partially responsible for the patient’s new neck pain, and ordered an MRI and attempted to consult neurosurgery before he was told that the findings were chronic changes which did not warrant additional work-up. This confusion and injudicious use of resources could have been avoided if the radiologist had not described the chronic changes in elaborate detail without explicitly first ruling out an acute process or mentioning that these changes were chronic changes seen on prior studies and not unexpected for the patient’s age.[[{"type":"media","view_mode":"media_crop","fid":"63831","attributes":{"alt":"Nitin Egbert, BS","class":"media-image media-image-right","id":"media_crop_3416966049176","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"8142","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 244px; width: 170px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Nitin Egbert, BS, Department of Radiology, The Ohio State University Medical Center","typeof":"foaf:Image"}}]]

So, why do we have a tendency to describe chronic changes in such detail? We all pursued our fascinating specialty because we are captivated by how anatomy and disease are uncovered by imaging and our keen attention to detail. It is simply natural for us to describe the nuances that are only appreciated by an expert’s trained eyes, and take pride in our ability to detect every finding. To provide value, we, however, must tailor our reports for our audience and generate clinically relevant reports. Another consideration is the potential fear of medicolegal consequences for not adequately describing a chronic finding that later becomes important. However, describing an irrelevant finding in excessive detail actually detracts from the value of the report, and may reinforce stereotypes among ordering providers that radiologists are not clinicians and are not able to provide clinically relevant reports. A failure to remain clinically relevant by not explicitly and clearly distinguishing among the reported findings can also often lead to longer hospital stays and unnecessary workup for the patient.

It is important to recognize that the question implicit in a clinican’s request is not merely something like “rule out a fracture” but rather “is there any acute or new process contributing to the current change in the clinical picture?” Reporting a finding without specifying whether it is part of an acute or chronic process can leave an unfamiliar reader wondering if this accounts for a patient’s acute presentation. Whenever there is an implicit question of an acute process in a study, and there is none, it adds the most downstream value to patient care to explicitly state that there is no acute process as the first point of the impression. Therefore, if there is no acute process, just say so.

Impression: 1) No fracture or other acute process. 2) Chronic degenerative changes of the cervical spine stable from the prior study.